Intraoperative Adverse Events in Abdominal Surgery: What Happens in the Operating Room Does Not Stay in the Operating Room

Abstract

INTRODUCTION: The relationship between intraoperative adverse events (iAEs) and postoperative outcomes remains largely unknown. We sought to assess the impact of iAEs on 30-day morbidity, 30-day mortality, and length of stay (LOS) among patients who underwent abdominal surgery. METHOD(S): The 2007 to 2012 institutional American College of Surgeons' NSQIP and administrative databases for abdominal operations were matched and then screened for iAEs using the ICD- 9-CM-based Patient Safety Indicator 'Accidental Puncture/Laceration.' A review of flagged charts was performed to confirm occurrence of iAEs. Univariate and then multivariable logistic regression models were constructed to assess the independent impact of iAEs on 30-day mortality, 30-day morbidity, and prolonged postoperative length of stay (>=7 days), controlling for preoperative/intraoperative variables (eg age, comorbidities, American Society of Anesthesiologists score, wound classification), procedure type (eg laparoscopic vs open, intestinal, foregut, hepatopancreaticobiliary vs abdominal wall procedure), and complexity (eg adhesions, relative value units). RESULT(S): There were 9,288 patients included; 183 had iAEs. Most injuries were addressed intraoperatively (92%), with 31% requiring tissue/ organ resection and/or significant impact on/incompletion of the procedure; 8% were initially missed and required reoperation. In multivariable analyses, iAEs were independently associated with increased 30- day mortality (OR 3.19, [95% CI 1.52-6.71], p=0.002) and morbidity (OR 2.68 [95% CI 1.89-3.81], p<0.001), including increased risk of deep/organ-space surgical site infection (OR 1.94 [95% CI 1.20-3.14], p=0.007), sepsis (OR 2.14 [95% CI 1.32- 3.47], p=0.002), pneumonia (OR 2.18 [95% CI 1.11-4.26], p=0.023), failure to wean off the ventilator >48 hours (OR 3.88 [95% CI 2.17-6.95], p<0.001), and prolonged postoperative LOS (OR 1.85 [95% CI 1.27-2.70], p=0.001) (Table). CONCLUSION(S): Intraoperative adverse events, even when recognized and repaired intraoperatively, are independently associated with substantially increased rates of postoperative mortality, morbidity, and prolonged LOS.